Renewing Primary Care: Lessons Learned from the Spanish Health Care System
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Lessons From Around The World By Jeffrey Borkan, Charles B. Eaton, David Novillo-Ortiz, Pablo Rivero Corte, and Alejandro R. Jadad doi: 10.1377/hlthaff.2010.0023 HEALTH AFFAIRS 29, NO. 8 (2010): 1432–1441 ©2010 Project HOPE— Renewing Primary Care: The People-to-People Health Foundation, Inc. Lessons Learned From The Spanish Health Care System Jeffrey Borkan (jeffrey_ [email protected]) is chair of ABSTRACT From 1978 on, Spain rapidly expanded and strengthened its the Department of Family primary health care system, offering a lesson in how to improve health Medicine at the Alpert Medical School, Brown outcomes in a cost-effective manner. The nation moved to a tax-based University, in Providence, Rhode Island. system of universal access for the entire population and, at the local level, instituted primary care teams coordinating prevention, health Charles B. Eaton is director of the Center for Primary Care promotion, treatment, and community care. Gains included increases in and Prevention at the Alpert life expectancy and reductions in infant mortality, with outcomes Medical School and director of the Heart Disease superior to those in the United States. In 2007 Spain spent $2,671 per Prevention Center at person, or 8.5 percent of its gross domestic product on health care, Memorial Hospital of Rhode Island, Brown University. versus 16 percent in the United States. Despite concerns familiar to Americans—about future shortages of primary care physicians and David Novillo-Ortiz is an — adviser for e-health at the relatively low status and pay for these physicians the principles Pan-American Health underlying the Spanish reforms offer lessons for the United States. Organization, in Washington, D.C., and a lecturer in the Department of Library Science and Documentation, Carlos III University, in Madrid, Spain. he recently enacted Patient Protec- than reform in the United States, it is instructive tion and Affordable Care Act in the to analyze Spain’s effort for applicable lessons. PabloRiveroCorteis Director United States outlines a major role In this paper we outline the principles under- General of Quality, Ministry of Health and Social Policy for a strengthened primary care lying the Spanish reforms and the key features of (Spain), in Madrid. system in improving health and the system that grew out of these principles. We Tcontrolling system costs. Although the United describe trends in health care delivery, spend- Alejandro R. Jadad is chief States has not often looked abroad for advice ing, and health outcomes that have occurred innovator and founder of the Centre for Global eHealth on its health care system, the renewed emphasis through the reform period. Innovation and holds the on primary care provides an opportunity to learn Canada Research Chair in from other nations that either have historically eHealth Innovation and the ’ Rose Family Chair in emphasized primary care s role in health care, History And Context Supportive Care. He is a have recently strengthened their primary care Following a protracted period of isolation under professor in the Departments systems, or have created horizontally and verti- the dictatorship of Francisco Franco (1939–75), of Health Policy, Management, cally integrated health care systems through Spain underwent a period of rapid renewal. The and Evaluation and of Anesthesia, and in the Dalla reforms. nation adopted a democratic style of govern- Lana School of Public Health, Spain, although often overlooked,1,2 provides ment, joined the European Union, liberalized University Health Network an example that could be instructive for other its markets, and grew its economy to a point and University of Toronto, in nations seeking to strengthen their primary care where it has become one of the twelve largest Ontario, Canada. systems. economies in the world as measured by gross The Spanish health system has undergone domestic product (GDP).8 rapid transformation, achieving impressive im- The post-Franco era was also marked by rapid provements in health status outcomes in a short reorganization and transformation in health time with relatively modest investments.2–7 care and social services. On June 4, 1977, the Although the Spanish health care system reform Ministry of Health and Social Security was cre- took root in a different sociopolitical context ated by the first democratically elected 1432 Health Affairs August 2010 29:8 government. The following year, the Spanish for which there are major access problems, such Constitution of 1978 declared the right of every as preventive gynecological care.11 citizen to health protection and care and re- The contemporary National Health System of quired the creation of a universal, general, and Spain incorporates both public and private free national health system that guaranteed health care systems. It provides universal cover- equal access to preventive, curative, and rehabili- age for citizens, foreign nationals—including tative services.9–14 Managerial and administrative undocumented immigrants within Spanish na- power over health services was transferred to the tional territory—as well as nationals of European Spanish National Institute of Health (Instituto Union (EU) Member States and non–EU Nacional de Salud, or INSALUD). Member States where rights are recognized by A rationale for a coherent health care structure applicable laws, treaties, or conventions.10–12 The was determined by first mapping and analyzing distribution of health care powers and duties, as all health care services within Spain on the level originally established by the 1978 Spanish of Autonomous Regions or Communities—sim- Constitution, was further clarified by the 1986 ilar to states in the United States. In 1981, juris- General Health Act and subsequent legislation. diction over health care was decentralized from The central government has power and the Spanish National Institute of Health to responsibility for the basic principles and co- Spain’s seventeen Autonomous Communities. ordination of health affairs, setting certain na- A strategy for care delivery was formulated by tional standards and pharmaceutical policy. It several Autonomous Communities using pri- also is in charge of the National Institute of mary care centers, primary care teams, service Health Management, which is responsible for coordination, and personalized services.13 the management of rights and obligations of In addition, the creation of family medicine as the National Institute of Health (INSALUD), a medical specialty contributed to higher stan- health benefits in two Spanish enclaves in North dards and a distinctive professional identity for Africa, and a variety of activities necessary for the primary care physicians.13 The transformation implementation of the key health laws. The was further formalized with the passage in Autonomous Communities control health plan- 1986 of the General Health Act (Ley General ning, public health, and the management of de Sanidad), enabling the creation of an inte- health services, while local councils oversee grated National Health System and agreement health and hygiene and collaborate in the man- on the range of health services that would be agement of public services.11,14 publicly funded throughout the country.9–12 Each Autonomous Community further distrib- The 1978–86 transition in Spain’s health care utes its health care services into Health Areas and system included a major shift in basic financing Basic Health Zones according to demographic, from a social insurance model to one that is tax- geographic, cultural, epidemiological, employ- based and the creation of a robust primary care ment, and other criteria. The key aim is to guar- sector. These two developments marked a dra- antee service proximity to users. Health Areas matic departure from the Franco era, when em- are responsible for the management of facilities, phasis was placed on the development of a social health services, and benefits within their geo- security–style system designed to provide spe- graphical limits. Each is mandated to cover a cialized services through a national network of population of 200,000–250,000 inhabitants.12 large hospitals. A Health Area is composed of several Basic The new emphasis on primary care was linked Health Zones, which constitute the framework to the decision at the outset of the transforma- for primary health care delivery. tion to provide universal access to health services Primary health centers are based in Basic for the entire population. The shift from social Health Zones, while each Health Area is assigned insurance contributions to taxes was accompa- a general hospital for referral to specialist nied by other major economic reforms, includ- care.11–13 Basic Health Zones are the smallest unit ing the separation of providers from purchasers of health care organization. They are usually and the conversion of hospitals to foundations organized around a single primary care team, or trusts.3,14 covering 5,000–25,000 inhabitants, and they co- Although most primary care in Spain is now ordinate prevention, promotion, treatment, and publicly funded, it is estimated that 15 percent of community care activities.12 the population holds private supplemental in- surance that covers benefits beyond those pro- vided by the National Health System.15 Tracking Progress: Outcomes And Supplemental health insurance may cover serv- Spending ices not covered by the public system, such as The 1978–86 transformation of Spain’s health dental care, or may facilitate entrée to services care system facilitated noteworthy progress in August 2010 29:8 Health Affairs 1433 Lessons From Around The World the delivery of high-quality and cost-effective Spanish health care transformation was to rely care. In 2007 Spain spent $2,671 per person, on a robust primary health care system, similar or 8.5 percent of gross domestic product in scope and infrastructure to the concept of the (GDP) on health care—which was below the aver- patient-centered medical home now taking hold age of 8.9 percent for countries in the Organiza- in the United States.17,18 Primary health care is tion for Economic Cooperation and Devel- characterized by extensive accessibility, with suf- opment (OECD).